Falling down

By Daniela Feuerlicht, Suzanne Sheppard-Law, Reece Hinchcliff*
Tuesday, 24 July, 2018

Falling down

Too often, children are being injured by falls while in hospital, presenting a significant challenge to healthcare providers. Two organisations step up to change the status quo.

Falls are a common cause of children being admitted to hospital and also being injured after admission to hospital. This presents a considerable moral and economic challenge to healthcare stakeholders in Australia and globally. Yet while hospital falls are already a national patient safety priority, there have been few investigations of the specific causes of hospital falls among children. Fortunately, the Sydney Children’s Hospital Network (SCHN) and the University of Technology Sydney (UTS) are stepping up to the national challenge of reducing falls in children’s hospitals.

The SCHN includes two major hospitals, the Children’s Hospital at Westmead and the Sydney Children’s Hospital at Randwick. Each year the SCHN has over 51,000 in-patient admissions, 92,000 emergency department presentations and over one million outpatient services. The large patient volume, clear emphasis on employing evidence-based practices and strong leadership of the SCHN make it an ideal organisation in which to examine the aetiology of paediatric falls. Working collaboratively with the Centre for Health Services Management and other UTS Faculty of Health academics, the SCHN is conducting a broad range of falls prevention research and intervention programs with national and international implications.

Interrogating the data

This body of work is exemplified by a recent innovative study that links falls data from organisational and state patient safety administrative reporting systems. Senior hospital management rely on the accuracy of these data to measure falls, monitor trends, report against falls-related national accreditation standards and inform patient safety strategies. However, all administrative datasets have inherent limitations due to selective definitions, coding challenges and other factors. This makes it necessary to critically interrogate and link the data from different systems to form a more complete picture of paediatric falls.

Over a one-year period at the SCHN, data linkage identified 146 paediatric falls reported in the state-wide incident reporting system and/or through routine data coding. This resulted in a falls rate of 0.88 per 1000 bed days for falls that were either physiological (ie, related to the child’s medical condition) or accidental, typically due to the hospital environment. Falls due to the child’s motor skill advancement were excluded, as they are not necessarily due to the hospital environment. These figures are similar to those reported internationally in paediatric facilities. However, there were considerable variations between the falls rates identified by the SCHN using different reporting systems. An important conclusion is that data linkage studies of this type should also be undertaken in other Australian paediatric hospitals to inform a more accurate understanding of national falls rates and trends.

Parental contribution

Additional research conducted by the SCHN has also illuminated several issues regarding the outcome of, main causes of and potential methods to reduce falls. For example, 43% of the patients who fell suffered some level of harm, including fractures. Almost half of the falls identified occurred at the patient’s bedside. Parents or carers were present for around half the falls, while healthcare workers were present in 20% of cases. Furthermore, while parents experience a strong need, and indeed expect, to be involved in the care of their child, the physical and psychological demands of hospital-based care on their parental role may also contribute to inpatient falls. Parental fatigue and less vigilant behaviour on the removal of bed or cot sides to comfort their child are commonplace. Preliminary findings from a recent qualitative study suggest that parents of hospitalised children prioritise their child’s general health and wellbeing, while giving little or no consideration to the specific risk of an inpatient fall, often increasing the chance of such incidents.

Emotional impact

While these figures are illuminating, it is equally important to retain appreciation for the emotional impacts of paediatric falls. As the following scenario indicates, these incidents affect not only the children involved, but also their families and the workers caring for them; it shows how simply, yet dramatically, falls can occur in paediatric hospitals:

James is a 3-year-old boy who has presented to the emergency department with abdominal pain. His mum and younger brother are with him. While waiting to be assessed by the doctor, James is sitting in a bed playing with toys. His mum has left the bed side down, to allow her to reach out and play with James. His mum is briefly distracted by James’s younger brother, and the toy James is playing with moves out of his reach. In his attempt to reach the toy, he loses his balance and falls out of the bed, hitting his head on the floor. James is distressed, and his mum feels guilty for not watching him more closely. James needs to stay in ED for 6 more hours to be monitored after hitting his head.

Fall prevention strategies

By understanding which children are at most risk of falls, and deducing reliable falls data to measure trends, the SCHN has been able to develop more nuanced falls prevention strategies. One approach has been to use simulated scenarios to increase their workforce’s knowledge of the primary causes of paediatric falls, and to improve the delivery of key falls prevention messages to consumers and their parents. These scenarios are modelled based on the qualitative and quantitative data collected regarding the main at-risk populations, parents’ perception of falls risks and the locations and processes most commonly involved in falls incidents.

It is vital for Australian healthcare stakeholders to develop more detailed understanding of falls in children’s hospitals and how to prevent them. The research and practical programs led by the SCHN in collaboration with UTS academics provide some early directions to inform the practices of other Australian paediatric hospitals. Key recommendations include the use of data linkage approaches to develop more accurate falls rates, and the use of simulation activities based on evidence-informed, realistic scenarios to foster workforce training in falls prevention and the development of family-centred education that reflects the needs of SCHN populations. Most importantly, we require greater national leadership and knowledge-sharing forums to ensure that Australian healthcare stakeholders continue to step up to the challenge of hospital falls among children.

For more information, visit the Centre for Health Services Management.

*Daniela Feuerlicht is the Acting Network Manager of Patient Safety in the Clinical Governance Unit of the Sydney Children’s Hospital Network.

Suzanne Sheppard-Law is a Senior Nursing Research Fellow at the University of Technology Sydney, Faculty of Health and the Sydney Children’s Hospital Network, Nursing Research Unit.

Reece Hinchcliff is a Senior Lecturer in the Centre for Health Services Management at the University of Technology Sydney and an Honorary Senior Research Fellow at the Australian Institute of Health Innovation, Macquarie University.

Image credit: ©stock.adobe.com/au/mizina

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